NBNE3008070322 | Comp/Mar/Int/5222

Contact Details - Self Declaration

Application no.: __________________________________________________________________________________________________________

Mobile no.: _____________________________________________________________________________________________________________

Email ID: _______________________________________________________________________________________________________________

Proposer/Life Assured Name: _______________________________________________________________________________________________

I Mr./Miss/Mrs. ________________________________________________________________ confirm that the mobile no./Email ID mentioned in the

proposal form and above can be used for processing the stated application.

Owner details of the Email ID/Mobile no. (Contact Owner):

Agent code/Employee Contact Owner Mobile number / Life Assured/ PPH Relationship Contact Owner
code/SP code Name Email ID with Contact Owner* Signature

Disclaimer:
The mobile number registered with us will be used for sending verification codes on your mobile number for authentication of service requests. It is
highly recommended to use your own mobile number which will help you keep a track of all the transactions and it will also help in prevention of an
unauthorized transaction being performed on your policy.

For customers registered under National Do Not Call Registry, this will be considered as consent to communicate with him/her on the contact details
provided herein.

* Eligible relationships whose contact details can be provided are spouse, parents, children, immediate siblings, grandparents, in laws.

SIGN HERE
DD/MM/YYYY
Date: __________________
Place: __________________
Life Assured / Proposer Signature

HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 1860-267-9999 (Local charges apply) | 022-68446530 (STD charges apply). Available Mon-Sat from 10 am to 7 pm. DO NOT prefix any country code e.g. +91 or 00. |
Email – service@hdfclife.com | nriservice@hdfclife.com (For NRI customers only) Visit – www.hdfclife.com